<%-- 
    Document   : jspRegistrarHistorial
    Created on : 20/09/2011, 12:36:39 AM
    Author     : yohanna
--%>

<%@page contentType="text/html" pageEncoding="UTF-8"%>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   "http://www.w3.org/TR/html4/loose.dtd">

<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <title>JSP Page</title>
    </head>
    <body>
        <form class="jotform-form" action="http://spanish.jotform.com/submit.php" method="post" name="form_12570535003" id="12570535003" accept-charset="utf-8">
  <input type="hidden" id="simple_spc" name="simple_spc" value="12570535003" />
  <input type="hidden" name="formID" value="12570535003" />
  <div class="form-all">
    <h2 id="header_1" class="style1">Historial Medico
          </h2>
    <ul class="form-section">
      <li class="form-line" id="id_3">
        <label class="form-label-left" id="label_3" for="input_3"> Historial
		Clínico # </label>
          <input type="number" id="input_3" name="q3_historialClinico" /><div id="cid_3" class="form-input">
          &nbsp;</div>
      </li>
      <li class="form-line" id="id_4">
        <label class="form-label-left" id="label_4" for="input_4"> Nombre Del Niño </label>
          <input type="text" class="form-textbox" id="input_4" name="q4_nombreDel" size="30" /><div id="cid_4" class="form-input">
          &nbsp;</div>
      </li>
      <table border ="1"cellspacing="1">
	<thead>
		<tr>
			<th style="width: 100px">FECHA</th>
			<th style="width: 112px">PESO</th>
			<th style="width: 131px">ALTURA</th>

		</tr>
	</thead>

	<tbody>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>
		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
		<tr>
			<td style="width: 100px">&nbsp;</td>
			<td style="width: 112px">&nbsp;</td>
			<td style="width: 131px">&nbsp;</td>

		</tr>
	</tbody>
</table>

      	<br />
		<br />
		<div id="cid_6" class="form-input-wide">
			<div style="text-align:derecha" class="style1">
				<button id="input_6" type="submit" class="form-submit-button">Observar
            	</button>&nbsp;&nbsp;&nbsp;&nbsp;
				<input name="Submit1" type="submit" value="Agregar" />&nbsp;&nbsp;&nbsp;&nbsp;
				<input name="Submit2" type="reset" value="Salir" /></div>
		</div>
    </ul>
  </div>
</form>
        <h1>Hello World!</h1>
    </body>
</html>
